Physician Trial Form

To be signed by doctor

A clinical procedure is being preformed with a demo C Scope tablet that does not automatically prevent scope reuse. The single-use scope kit items must be discarded once the procedure is complete.

To be signed by sales rep

The C Scope handpiece has been reprocessed with Caviwipes according to the user manual and all patient information gathered during the trial procedure has been deleted from the C Scope tablet.

Thank you! Your form has been submitted.